Endocrine Abstracts

Background: Graves disease is a resurgent autoimmune condition that is known to occur during treatment and immune reconstitution in HIV, and it is one of the commonly diagnosed endocrinopathies in these patients. Graves orbitopathy, on the other hand, is a situation that occurs less frequently. We report the clinical features and manifestations of thyroid-associated orbitopathy in a case of an HIV patient with Graves disease.

Case Presentation: A 48-year-old woman presented with spontaneous retrobulbar pain, exophthalmos, periodic diplopia, palpebral edema, and conjunctival hyperemia. The symptoms reported appeared and advanced during the previous 12 months. Anamnesis revealed that she was diagnosed with Graves disease 3 years ago and is on antithyroid medication and beta-blockers with moderate success in achieving euthyroidism. The patient is also receiving antiretroviral treatment for the last 5 years, as she was diagnosed with HIV 10 years ago. The patient is a chronic tobacco user, for about 30 years. On admission, the patient had freeT4 - 35,3 pmol/l, freeT3 - 12,0 pmol/l, and antithyroid medication was adjusted to obtain euthyroidism. On the clinical examination, we appreciated a CAS score of 5 points and a moderate to severe case of ophthalmopathy, confirmed on MRI by hypertrophic orbital muscles. At the moment, the patient was aviremic and with a CD4 cell count of 665. The patient was started on pulse therapy with 750 mg of methylprednisolone, continued for 6 weeks, and 500 mg the following 6 weeks. No serious side effects were reported during treatment with steroids. Exophthalmos was the only remaining symptom after treatment, CAS score was reduced to 1 point.

Conclusions: Graves orbitopathy in HIV patients is uncommon and is not well-described in the literature. Many challenges may appear in these patients, especially regarding pharmacological interactions of antiretroviral, antithyroid and steroid drugs. Still, in our particular case, first-line treatment with steroids was efficient in reducing ophthalmopathy symptoms.